脊柱后路去松质骨截骨术用于脊柱畸形翻修手术的安全性和有效性

The effectiveness and safety of revision surgery with vertebral column decancellation for spinal deformity

中文关键词:  脊柱畸形  翻修术  矢状面平衡  截骨术

英文关键词:Spinal deformity  Revision surgery  Sagittal balance  Osteotomy

中文摘要:

  【摘要】 目的：探讨脊柱后路去松质骨截骨术（vertebral column decancellation，VCD）应用于脊柱畸形翻修手术中的安全性和有效性。方法：回顾性分析2010年1月~2012年1月在我院接受脊柱畸形翻修手术的20例患者的临床资料，年龄17～58岁（34.5±11.6岁），男12例，女8例。强直性脊柱炎后凸畸形6例，先天性半椎体后凸畸形4例，结核性脊柱侧后凸畸形4例，先天性侧后凸畸形3例，青少年特发性脊柱侧凸3例。翻修手术距初次手术时间为5.6±3.3年（1～16年）。翻修术前10例冠状面失衡患者冠状面Cobb角45°～85°（64.2°±15.6°），17例矢状面失衡患者矢状面畸形后凸Cobb角75°～110°（92.7°±9.7°）。均在插管全麻下行VCD进行畸形矫正。记录患者翻修手术时间、术中出血量及围手术期并发症等一般情况。所有患者翻修术前、术后1周及末次随访均拍摄包括骨盆的站立位脊柱全长正侧位X线片，测量脊柱矢状面、冠状面Cobb角，冠状位顶椎偏移距离、双肩相对高度差，矢状面偏移距离、矢状位腰前凸角、胸腰段后凸角、骨盆倾斜角、骨盆入射角及骶骨倾斜角。采用SRS-22调查表评估患者术前及术后6个月生存质量。结果：均顺利完成手术，平均截骨椎体数量1.5±0.6个（1～2个）。手术时间为4～6.5h（5.3±0.7h），术中出血量为600～1300ml（830.0±150.5ml）。所有患者术中脊髓监测未发现在复位过程中有体感诱发电位（SEP）及运动诱发电位（MEP）异常变化，术中唤醒试验患者下肢运动感觉功能正常。术后切口均Ⅰ期愈合。3例发生脑脊液漏，2例后凸畸形患者术后并发肠系膜上动脉综合征，围手术期未发生感染、呼吸衰竭、下肢深静脉血栓等其他并发症。住院时间13.9±2.4d。随访时间18～40个月（27.6±2.8个月），随访期间未出现内固定棒断裂、螺钉松动及深部感染等并发症。冠状面和矢状面畸形获得良好矫正，术后1周冠状面和矢状面Cobb角分别矫正至15.7°±4.9°、28.7°±8.7°。术后1周脊柱冠状面和矢状面Cobb角、顶椎偏移距离及双肩相对高度差、矢状面偏移距离与翻修术前比较均明显变小（P＜0.05），末次随访时与术后1周比较无统计学差异（P>0.05）；脊柱-骨盆矢状面参数除骨盆入射角与术前比较无统计学差异（P＞0.05）外，腰前凸角、胸腰段后凸角、骨盆倾斜角及骶骨倾斜角与术前比较均有明显改善（P<0.05）。术后1周冠状面Cobb角矫正率为（75.5±4.5）%，矢状面Cobb角矫正率为（63.5±5.7）%；末次随访时与术后1周比较，冠状面矫形丢失率为26.5%，矢状面矫形丢失率为34.1%。翻修术后6个月SRS-22量表功能、疼痛、外观、精神健康、满意度评分与翻修术前比较均明显增加（P<0.05）。结论：VCD在脊柱畸形翻修手术中可重新恢复脊柱矢状面、冠状面的平衡和稳定，尤其在脊柱矢状面平衡的恢复中有良好的效果，同时可避免脊髓过度短缩、神经卡压等并发症，是一种较安全有效的补救措施。

英文摘要:

  【Abstract】 Objectives: To evaluate the effectiveness and safety of revision surgery for the severe spinal deformity by utilizing the technique of vertebral column decancellation(VCD). Methods: A retrospective analysis was carried out for 20 cases suffered from spinal deformity and undergoing revision surgery in 301 Hospital from January 2010 to January 2012. Age ranged from 17 to 58 years old and the average age was 34.5±11.6 years. There were 12 males and 8 females. Twenty patients included 6 cases with kyphosis secondary to ankylosing spondylitis, 4 cases with congenital kyphosis, 4 cases with kyphoscoliosis secondary to spinal tuberculosis, 3 cases with congenital kyphoscoliosis and 3 patients with adolescent idiopathic scoliosis, all patients were diagnosed by the radiographic and medical records. The average interval from revision surgery to previous corrective surgery was 5.6±3.3 years. The mean Cobb angle of coronal plane was 64.2°±15.6° and 92.7°±9.7° in sagittal plane. All cases received revision surgery of VCD under general anesthesia. Operation time, intraoperative bleeding and the complications of perioperation were recorded. All 20 study subjects underwent whole spinopelvic right and lateral radiography at the time of pre-revision surgery, one week after revision and the final follow-up. Sagittal parameters included Cobb angle, thoracolumbar kyphosis angle(TK), lumbar lordosisc(LL), sacral slope(SS), pelvic tilt(PT), pelvic incidence(PI) and sagittal vertical axis(SVA). Coronal parameters included Cobb angle, apical vertebral offset distance and the relative height of shoulders. Scoliosis Research Society-22(SRS-22) was used to evaluate the life quality of 20 patients at different time points pre-revision surgery and 6 months of post-operation. Results: All surgeries were performed successfully, osteotomies were performed at 1.5±0.6 levels(average, 1-2). Time of revision surgery ranged from 4 to 6.5 hours(average, 5.3±0.7h) and the blood loss ranged from 600 to 1300ml(average 830.0±150.5ml). All incisions healed by first intention. No complication occurred such as infection, deep venous thrombosis of lower extremities, respiratory failure or nerve injury occurred during follow-up. Three cases suffered from leakage of cerebrospinal fluid and two cases were complicated with arteria mesenterica superior syndrome. The average hospital stay of all cases was 13.9±2.4 days. The follow-up ranged from 18 months to 40 months(average, 27.6±2.8 months). The Cobb angle was corrected to 15.7°±4.9° in coronal plane and 28.7°±8.7° in sagittal plane. Cobb angle of coronal plane, apical vertebral offset distance and the relative height of shoulders at one week after operation obviously improved than pre-revision surgery(P<0.05). And there was no statistical significance compared to final follow-up. The sagittal parameters except PI including Cobb angle, TK, LL, SS, PT, SVA at one week after revision operation had statistical significance compared to pre-revision surgery(P<0.05). The correction rate of coronal Cobb angle was (75.5±4.5)% and sagittal Cobb angle was (63.5±5.7)%. The loss of correction at final follow-up compared to one week after revision surgery was 26.5% in coronal plane and 34.1% in sagittal plane. The parameters of SRS-22 such as function, pain, appearance, mental and satisfaction of 6 months after revision surgery improved obviously compared to pre-revision surgery(P<0.05). Conclusions: The posterior VCD can restore the balance and stabilization of coronal and sagittal of spine, also can avoid the complications such as the excessive shorten and nerve injury of spinal cord in the procedure of revision severe spinal deformity surgery. This technique is an safe and effective remedial measure for spinal deformity after previous surgery.